CLGS-32-6 (05/17)

                 RESIDENCY CERTIFICATION FORM
                 Local Earned Income Tax Withholding

                 TO EMPLOYERS/TAXPAYERS:
This form is to be used by employers and taxpayers to report essential information for the collection and distribution of Local Earned Income Taxes 
to the local EIT collector. This form must be used by employers when a new employee is hired or when a current employee notifies employer 
       of a name or address change. Use the Address Search Application at dced.pa.gov/Act32 to determine PSD codes, EIT rates, 
                 and tax collector contact information.
                 EMPLOYEE INFORMATION – RESIDENCE LOCATION
NAME (Last Name, First Name, Middle Initial)                                                                 SOCIAL SECURITY NUMBER

STREET ADDRESS (No PO Box, RD or RR)

ADDRESS LINE 2

CITY                                                                                                                 STATEZIP CODE DAYTIME PHONE NUMBER

MUNICIPALITY (City, Borough or Township)

COUNTY                                                                                                           RESIDENT PSD CODETOTAL RESIDENT EIT RATE

                 EMPLOYER INFORMATION – EMPLOYMENT LOCATION
EMPLOYER BUSINESS NAME (Use Federal ID Name)                                                  EMPLOYER FEIN

STREET ADDRESS WHERE ABOVE EMPLOYEE REPORTS TO WORK (No PO Box, RD or RR)

ADDRESS LINE 2

CITY                                                                                                                 STATEZIP CODE PHONE NUMBER

MUNICIPALITY (City, Borough or Township)

COUNTY                                                                                                           WORK LOCATION PSD CODE                  WORK LOCATION NON-RESIDENT EIT RATE

                                                    CERTIFICATION
               Under penalties of perjury, I (we) declare that I (we) have examined this information, including all accompanying 
                 schedules and statements and to the best of my (our) belief, they are true, correct and complete.
SIGNATURE OF EMPLOYEE                                                                                           DATE (MM/DD/YYYY)

PHONE NUMBER                                                                                              EMAIL ADDRESS

For information on obtaining the appropriate MUNICIPALITY (City, Borough, Township), PSD CODES, and EIT (Earned Income Tax) RATES,
               please refer to the Pennsylvania Department of Community & Economic Development website:

                                                    dced.pa.gov/Act32